Provider Demographics
NPI:1720148802
Name:SO, ANDREW L (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:L
Last Name:SO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27189
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-0189
Mailing Address - Country:US
Mailing Address - Phone:302-224-5678
Mailing Address - Fax:302-224-2848
Practice Address - Street 1:8835 GERMANTOWN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-2718
Practice Address - Country:US
Practice Address - Phone:302-224-5678
Practice Address - Fax:302-224-2848
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041550E207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001248529 0001Medicaid
PA674433Medicare ID - Type Unspecified
PA001248529 0001Medicaid